Nclex review - 1
At 32 weeks' gestation, a client has an order for an ultrasound. The nurse determines the client understands the procedure if the client states which of the following? 1. "The results will inform us of the gestational age." 2. "This test will evaluate the baby's lungs." 3. "The test will show us if there is any problem in the spinal cord." 4. "Early problems with the baby's blood can be identified with this test."
"The results will inform us of the gestational age." Strategy: Think about each answer. (1) correct—ultrasound detects the gestational age, growth patterns and size (2) determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis (3) determined with an amniocentesis (4) determined with an amniocentesis
Amniocentesis
"The test will show us if there is any problem in the spinal cord." 4. "Early problems with the baby's blood can be identified with this test."
The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which of the following responses by the nurse is BEST? 1. "The father transmits the gene to his son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of her daughters."
(1) affected male inherits gene from his mother and can transmit it only to his daughters (2) it is not an autosomal recessive trait (3) correct—hemophilia is a sex-linked disorder (4) there is a 50% chance that the mother will pass the trait to each of her children
A 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which of the following? 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle. 5. playing peek-a-boo 6. rolling from back to the abdomen
(1) pincer present at 9 months of age (2) correct-6-month-old should sit with help. (3) 3x wt present at 1 year. (4) fontanelle is closed by 2 to 3 months (5) should be able (6)should be able
Parathyroid hormone action
-Regulates phosphorus and calcium in the body and -functions in neuromuscular excitation and blood clotting.
The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis? 1. The leg appears to be shortened and is adducted and externally rotated. 2. Plantar flexion is observed with sciatic pain radiating down the leg. 3. From the hip, the leg appears to be longer and is externally rotated. 4. There is evidence of paresis with decreased sensation and limited mobility.
1) CORRECT — accurate assessments of the position of a fractured hip prior to repair
the admitting nurse attaches an internal fetal monitor. The nurse knows which of the following is the MOST important reason for the fetal monitor? 1. To evaluate the progress of the client's labor. 2. To assess the strength and duration of the client's contractions. 3. To monitor the oxygen status of the fetus during labor. 4. To determine if an oxytocin drip is necessary.
1) clinical assessments provide information about progress of labor (dilation and effacement) 2) not most important reason for monitoring 3) CORRECT — goal is early detection of mild fetal hypoxia 4) fetal well-being is most important reason for fetal monitoring
The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring? 1. Bounding peripheral pulses. 2. Chills. 3. Respiratory wheezing. 4. Lower back discomfort.
1) seen with circulatory overload; severe anaphylactic reaction may cause hypotension 2) indicative of a hemolytic or febrile transfusion reaction 3) CORRECT — allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema 4) indicative of a hemolytic transfusion reaction
The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? Kwell shampoo for lices
1) too frequent an application of the rinse 2) wash with detergent in very hot water and dry for 20 minutes in a dryer 3) CORRECT— may be repeated 7 days after first application 4) hair should be combed daily with a nit comb
types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism? 1. Foods high in phosphorus. 2. Foods high in calcium. 3. Foods low in sodium. 4. Foods low in potassium.
1. diet should be low in phosphorus; hypoparathyroidism is decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm 2) CORRECT—diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance 3) not regulated by the parathyroid 4) not regulated by the parathyroid
Normal adjustment to terminal illness
1st stage: Denial and isolation 2nd stage: Anger 3rd: Bargaining (negociation) 4rd: Depression 5th: Acceptance
The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.
2) CORRECT — infant should be NPO 3 hours prior to the procedure
The physician writes an order for a stat dose of Demerol 50 mg IM for pain. Three hours later the client again complains of pain, and the nurse administers a second injection of Demerol. Which of the following describes the nurse's liability? 1. The nurse administered the medication appropriately; there is no liability. 2. There is no order for a second dose of medication; the nurse is liable. 3. The client was not injured; if injury did not occur, then the nurse is not liable. 4. The nurse should have waited at least 4 hours; then there would be no liability.
2) CORRECT — order for a stat dose is for a one time administration; nurse practice act addresses scope of practice; by administering a second dose the nurse was prescribing the medication, something only a healthcare provider with prescriptive ability can do; nurse was practicing medicine, not nursing and was outside of scope of practice
The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.
3) CORRECT - temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids
The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action? 1. No special actions are necessary. 2. Wear a double mask and gloves. 3. Perform good hand washing. 4. Wear a gown and a mask.
3) CORRECT — good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients
Which is most important for the rehabilitation nurse to assess during a new client's admission? 1. The client's expectations of family members. 2. The client's understanding of available supportive services. 3. The client's personal goals for rehabilitation. 4. The client's past experiences in the hospital.
3) CORRECT — it is important for the nurse to understand what the client expects from the rehabilitation program for future success
The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. 2. Responding in kind to a client who uses abusive language will perpetuate the behavior. 3. Abusive language is one of the behaviors symptomatic of the client's illness. 4. The nurse should model acceptable behavior and language for all clients.
3.) CORRECT — symptoms will respond to treatment
Febrile transfusion reaction
30 minutes to 6 hours after infusion ends; most common
The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? 1. The client's electrolytes. 2. The client's urine output. 3. The client's weight. 4. The client's heart rate.
4) CORRECT - verapamil is indicated for the treatment of supraventricular tachycardia, so the client's heart rate should be checked prior to administration
The nurse identifies which finding has the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)? 1. Perseveration. 2. Aphasia. 3. Mnemonic disturbance. 4. Apraxia.
4) CORRECT — apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly
The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis? 1. Social interaction impairment. 2. Potential activity intolerance. 3. Powerlessness. 4. Difficulty with coping.
4) CORRECT — client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is inability to cope
The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? 1. Inability to talk. 2. Loss of the gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.
4. client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye
The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip?
42 gtt/min
Generativity versus stagnation.
45-64 years of age
The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?
500 calories more at day in order to obtain milk production.
Integrity versus despair and disgust.
65 y/o ↑
Norepinephrine action
A catecholamine precursor of epinephrine that is secreted by the adrenal medulla and also released at synapses. -Enhancing musculoskeletal activity.
Epinephrine action
A catecholamine secreted by the adrenal medulla in response to stress preparing -the body for "flight or fight" (trade name Adrenalin)
Preeclampsia
Abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria (loss of protein in urine), and edema
Dystonia
Abnormal muscle tone that causes the impairment of voluntary muscle movement
Hemophilia
An X-linked recessive disorder in which blood fails to clot properly, leading to excessive bleeding if injured.
Artificial passive immunity
Antibodies from another person or animal that are injected into a human (tetanus). used to protect person exposed to serious disease
verapamil (Calan)
Antidysrhythmic class IV; antihypertensive: CA channel blocker
Hallucinations
Are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone.
Rationalization
Attempt to make behavior appear to be the result of logical thinking.
Quinidine antiarrhythmics
Class 1A Na blocker -Use: ventricular arrhythmias, recurrent atrial arrhythmias. -Prevents premature ventricular contractions (PVCs).
The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information?
Colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination. to assist in establishing a normal pattern of elimination colostomy should be irrigated only once a day solution should be at body temperature;
pituitary dwarfism
Condition of congenital hyposecretion of growth hormone slowing growth and causing short yet proportionate stature (not affecting intelligence), often treated during childhood with growth hormone; other forms of dwarfism are most often caused by gene defects.
Delusions of persecution.
Delusion is a strongly held belief that is not validated by reality; the idea that his brother is trying to steal his property is a belief not validated by reality.
The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom?
Delusions of persecution.
Delusions of reference
Delusions of reference are a false belief that public events or people are directly related to the individual.
Parallel play
Describes play for a toddler
Solitary play
Describes play for an infant
The nurse cares for a patient receiving chlorpromazine hydrochloride (Thorazine). The nurse notes the patient is restless, unable to sit still, and complains of insomnia and fine tremors of the hands. The nurse identifies which of the following as the BEST explanation about why these symptoms are occurring? 1. A side effect of the medication that will disappear as time passes. 2. The reason the patient is receiving this medication. 3. Extrapyramidal side effects resulting from this medication. 4. An indication that the dosage of the medication needs to be increased.
Determine how each answer relates to Chlorpromazine hydrochloride (Thorazine) (1) untrue statement; dosage may need to be decreased because of side effect of medication; antiparkinsonian drug such as Cogentin benztropine may be ordered (2) not accurate; antipsychotic medication (3) correct—side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing) (4) dosage may be decreased; antiparkinsonian drug such as Cogentin benztropine may be ordered
The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Polyuria and hypertonic reflexes.
Determine how each answer relates to pre-eclampsia. 1) only partially correct; blurred vision appears later, with eclampsia 2) contains signs of eclampsia before a seizure 3) CORRECT — represents two of the three symptoms seen with pre-eclampsia; also includes hypertension 4) oliguria is seen later with eclampsia
Intellectualization
Excessive reasoning or logic used to avoid experiencing disturbing feelings.
Early signs of lithium toxicity? 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting .5. Orthostatic hypotension. 6. Diarrhea
Fine tremors, nausea, vomiting, diarrhea. 1) CORRECT - A symptom of toxicity. 2) Associated with antipsychotics. 3) Associated with severe lithium toxicity. 4) CORRECT - An early symptom. 5) Associated with antipsychotics. 6) CORRECT - An early symptom.
TB symptoms
Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.
IVP- Intravenous pyelogram
IV dye is injected & diagnostic x-rays of entire urinary tract taken. performed to: -detect kidney tumors -identify blockages or obstructions of normal urine flow -detect kidney or bladder stones -establish is prostate gland is enlarged -detect injuries to urinary tract
Internalization
Incorporation of someone else's opinion as one's own.
Aggressive play
Is not play but a behavior
early stages of nephrotic syndrome.
Loss of large amounts of plasma protein, usually albumin through the urine due to increased permeability of the glomerular membrane.
Narcotics
Mood-altering drugs most often associated with an increased risk for HIV infection related to intravenous drug use
Expiratory wheezing and substernal retractions.
More often noted with respiratory distress of the newborn
Cellilitis in drug addicts
Most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus.
akathisia
Motor restlessness such as fidgeting, rocking, or pacing due to the neuromuscular or neurologic adverse effects associated with the use of antipsychotics
Abduction
Movement away from the midline
Adduction
Movement towards the midline
The nurse cautions the client with hypothyroidism to avoid which implementation?
Narcotic sedatives. —client is very sensitive to narcotics, barbiturates, and anesthetics
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication?
Pressure on the ocular suture line. rationale: sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line.
SHARE
SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage.
VDRL test
Screening test for syphilis. -Positive test indicates need for Tx w/ antibiotics
Symbolization
Something represents something else; symbolization is involved in phobias
The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Rice cereal is usually the first solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the first solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) CORRECT - infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later 2) inaccurate 3) does not answer the parent's question 4) usually started between 4 and 5 months of age
The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first? 1. Instructs the significant other about the medication regimen. 2. Determines the client's comprehension of the medication administration. 3. Prepackages the medication to encourage correct administration. 4. Encourages a return demonstration of medication self-administration.
Strategy: Answers are a mix of assessment and implementation. Does this situation require assessment? Yes. 1) implementation; might be done after assessment of the comprehension level 2) CORRECT — assessment; intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdose and underdose 3) implementation; might be done after assessment of the comprehension level 4) implementation; might be done after evaluation of the comprehension level
18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB), early symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.
Strategy: Determine how each answer relates to croup. 1) Kussmaul respirations are associated with diabetic ketoacidosis; hypoxia and anxiety are associated with tachycardia 2) respiratory rate would be increased 3) more often noted with respiratory distress of the newborn 4. correct- Inspiratory stridor and restlessness. —this condition is characterized by edema and inflammation of upper airways
Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. "The client is unable to complete activities of daily living without assistance." 2. "The client appears to be depressed and anxious regarding impending surgery." 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family is unable to visit more often than once a week because they live far away."
Strategy: Good documentation is the objective. 1) does not describe emotional adjustment 2) draws conclusions without supporting data 3) CORRECT — gives an objective description of the client's behavior and affect 4) describes the client's family, not the client
The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client? 1. The client 1 day postop after an internal fixation of a fractured left femur. 2. The client receiving diltiazem and phenytoin. 3. The client ordered to receive two units of packed cells. 4. The client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Strategy: The RN cares for clients who require assessment, teaching, and nursing judgment. 1) care can be assigned to the nursing assistive personnel; standard, unchanging procedure 2) medication can be given by the LPN 3) CORRECT — requires the assessment and teaching skills of the RN 4) offer food and fluids; assign to the LPN
The nurse cares for the prenatal client at 8 weeks' gestation with a positive VDRL (syphilis). When the nurse prepares the teaching plan, it is MOST important for the nurse to include which of the following? 1. Advise the client to not take any over-the-counter medications. 2. Instruct the client on the importance of taking the medication for the prescribed time. 3. Inform the client to refrain from sexual activity. 4. Maintain the confidentiality of sexual partners or contacts.
Strategy: Think "Maslow." (1) physical, should not take medication over the counter unless prescribed by a doctor, but not highest priority (2) correct—physical, vitally important to complete all the penicillin (3) physical, more important to be treated for disease (4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so that they may be treated
The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? 1. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. 2. Clomiphene citrate changes the uterine lining to be more conducive to implantation. 3. Clomiphene citrate alters the vaginal pH to increase sperm motility. 4. Clomiphene citrate produces multiple pregnancy for those who desire twins.
Strategy: Think about each answer. 1) CORRECT — clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum 2) infertility problem, but clomiphene citrate does not affect it 3) infertility problem, but clomiphene citrate does not affect it 4) not a desired effect
CANDLELIGHTERS
Support group for families who have lost a child to cancer.
RESOLVE
Support group for infertile clients.
Lumbar disc injury
Symptoms - pain in the back or lower extremities, abnormal sensation and weakness, paresis and limited mobility.
renal threshold
The concentration at which a substance in the blood that is not normally excreted by the kidneys begins to appear in the urine.
mannitol (Osmitrol)
Therapeutic class/Mechanism: Osmotic diuretic Primary use: Increased intracranial pressure, to promote diuresis in renal failure, increased intraocular pressure (narrow-angle glaucoma), to promote excretion of renal toxins
Associative play
This is the play that characterizes 4-year-olds
Webber test
Tunning fork on midline of skull, pt idenities sound that is loudest, normal hearing sound is heard equally, sound louder in ear with hearing loss, softer in ear with sensorineural hearing loss.
Blood transfusion allergic reaction
Type I hypersensitivity reaction against plasma proteins in transfused blood -Mild: urticaria, pruritus, facial flushing -Anaphylaxis: -hypotension, dyspnea, wheezing, -↓O Sat -fever -flushing -epiglottal edema -TX: with antihistamines
Intimacy versus isolation.
Young adult
clomiphene citrate (Clomid)
a nonsteroidal synthetic antiestrogen used to induce ovualation
Identity versus role diffusion.
appropriate for the adolescent
Kussmaul respirations
are associated with diabetic ketoacidosis
Test to evaluate the baby's lungs."
determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis
Rinne test
hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction
Natural active immunity
- antigen enters the body without human assistance; body responds by actively making antibodies
A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which of the following? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization.
(1)correct— -projection (attributing one's thoughts or impulses to another -displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)
EDTA
-Best substance to remove lead from blood chelation therapy, -Anticoagulant in lavender top tubes
Lead poisoning
-Poisoning caused by an elevated level of lead in the human body that can result in damage to the -brain: (↑ICP, shift of fluids in brain, intellectual deficiencies, mental retardation, convulsions, death), - nervous system, -kidneys, -blood., -Microcytic Anemia (initial sign)
Hip fracture care
-Position pt to non operative side -Maintain abduction pillow between legs -ambulate pt the first post op day( pt transfer to a chair w / assistance and begings assisted ambulation) -Never flex the hip > 90 degrees -HOB no more than 60 degress
The nurse knows that cortisol is responsible for which action?
-Responsible for converting proteins and fat into glucose. -An adrenal-cortex hormone (trade names Hydrocortone or Cortef) that is active in carbohydrate and protein metabolism. -is also an anti-inflammatory agent
Lead poisoning antidote
-dimercaprol (also used for other poisonings - gold, arsenic, mercury) -EDTA -succimer (Chemet)
The health care provider orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication? 1. The blood pressure increases to 150/90. 2. Urinary output increases to 175 mL/hour. 3. There is a decrease in the level of activity. 4. There is an absence of fine tremors of the fingers.
1) increase in blood pressure is not desired 2) CORRECT — mannitol is an osmotic diuretic; increases urinary output and decreases intracranial pressure 3) does not indicate desired effect of medication 4) does not indicate desired effect of medication
The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? 1. There is no drainage in the collection chamber for 3 hours. 2. The fluid in the water-seal chamber does not fluctuate with respirations. 3. There is continuous bubbling in the water-seal chamber. 4. There is gentle bubbling in the suction control chamber.
2) CORRECT — indicates no more air leaking into pleural space 3) indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling 4) normal finding
The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1. Jaundice. 2. Rash. 3. Bruising. 4. Cellulitis.
Determine how each answer relates to IV drug abuse. 1) jaundice can develop because of hepatitis B and cirrhosis, which may occur in narcotic abusers who use intravenous drugs 2) may occur because of the chemicals that are used in cutting the drugs by the client or the drug dealer 3) may occur because of the chemicals that are used in cutting the drugs by the client or drug dealer 4) CORRECT — most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus
Encourage fluids for a toddler with lead poisoning.
-Milk: contains calcium; calcium binds to lead and inhibits its absorption -purpose of the treatment is to remove lead from the blood and soft tissues.
Reaction formation and symbolization
Development of conscious attitudes and behavior patterns into opposite of what one really wants to do)
Pacemaker
Device that delivers electrical impulses to the heart to regulate the heartbeat and main purpose is to ↑ CO
Dyskinesia
Distortion or impairment of voluntary movement such as in a tic or spasm
A client with an endotracheal tube requires suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure? 1. Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenate the client. Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion. 3. Explain the procedure to the patient. Insert the catheter gently while applying suction, and withdraw using a twisting motion. 4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.
(1) catheter is inserted until resistance is met; never suction longer than 10-15 seconds. (2) use twirling motion when withdrawing catheter not back and forth (3) suction is never applied when catheter is inserted. (4) correct—insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion
The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST? 1. A mother reports the umbilical cord of her 5-day-old infant is dry and hard to the touch. 2. A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps. 3. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate. 4. A father reports that he bumped the crib of his 2-day-old infant and she violently extended her extremities and returned them to their previous position.
(1) umbilical cord should be dry and hard; draining indicates possible infection and needs assessment (#3) (2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure and is serious (#1) (3) circumcision should have yellow exudate, but swelling is not normal and may effect urination. (#2) (4) motor reflex is normal; disappears after 3 to 4 months (#4)
Cardiac Glycosides (Digoxin)
-Cardiac drug derived from plant sources such as the Digitalis plant and Foxglove -Digoxin -Improves cardiac contractility and reduces energy and oxygen demand -VERY narrow therapeutic window. -↑the force of myocardial contraccion
Hemolytic transfusion reaction
-Destruction of erythrocytes that occurs when a patient receives a transfusion of mismatched blood -hypotension, ↑PR, U/O, hematuria -chills -lower back pain, -fever, -nausea, vomiting -flushing, -bleeding, shock, -hemoglobinuria (life threatening).
Foot drop
-Permanent dysfunctional position caused by shortening of the calf muscles and lengthening of the opposing muscles on the anterior leg. - The foot falls down at the ankle; permanent plantar flexion
Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1. The client has an allergy to shellfish. 2. The client has diminished palpable peripheral pulses. 3. The client has cool lower extremities bilaterally. 4. The client is anxious about the pending procedure.
1) CORRECT — allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure - Procedure where a catheter is inserted into an artery and guided into the heart; may be used for diagnosis of blockages or treatment, -Thin, flexible tube is guided into the heart via a vein or an artery and after contrast material is introduced, blood pressure is measured, and x-rays taken to image patterns of blood flow. - check allergies for shellfish
The client develops a postoperative infection and receives ceftriaxone sodium (Rocephin) IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.
1) CORRECT — cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended
The nurse cares for the client with ataxia. Which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist. 4. Elevate the foot of the bed.
1) CORRECT — client's coordination is poor; the only relevant nursing action is to supervise ambulation
he nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate? 1. "You are less likely to awaken during the night with heartburn if the stomach is empty." 2. "Early-morning vomiting will be less of a problem if the stomach is empty." 3. "Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs." 4. "You may develop fluid overload if fluids are taken just before going to bed."
1) CORRECT — full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn 2) vomiting is not related to hiatal hernia 3) decreased respirations are not related to hiatal hernia 4) fluid overload is not related to hiatal hernia
Nephrotic syndrome diet 1. Adequate protein, low sodium intake. 2. Low protein, low potassium intake. 3. Low potassium, low calorie intake. 4. Limited protein, high carbohydrate intake.
1) CORRECT — if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted
The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client? 1.Eat a vegetarian diet for 1 week before the test. 2. Limit alcohol intake to two glasses of wine the day before the test. 3. Abstain from dairy products for 48 hours before the test. 4. Only take sips of water for 12 hours before the test.
1) client should eat a normal diet the week before the test 2) alcohol intake will interfere with test results 3) normal diet should be eaten the week before the test 4) CORRECT — only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results
The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client? 1. Problem with verbal communication. 2. Inadequate airway clearance. 3. Possible skin integrity impairment. 4. Acute pain.
1) correct diagnosis; however, answer choice 2 is the priority 2) CORRECT — inadequate airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions. 3) correct diagnosis; however, answer choice 2 is the priority 4) tracheostomy is not usually painful
Enema position: The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. The LPN/LVN positions the client left Sims' position.
1) could cause rapid infusion and possible painful distention of the colon 2) is not feasible during the administrative phase 3) tube should be inserted no more than 4 inches 4. CORRECT- allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution. positions the patient left side-lying (Sim's) with knee flexed.
The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process? 1. Elderly adults eat a small volume of food with decreased bulk. 2. Elderly adults engage in less activity and have decreased GI muscle tone. 3. Elderly adults have neurological changes in the gastrointestinal tract. 4. Elderly adults have decreased sensation in the gastrointestinal tract.
1) decreased intake of high-fiber foods due to chewing difficulties is seen but is not a major cause of constipation 2) CORRECT — reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, adverse effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat 3) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation 4) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation
BEST way for a nurse to assess the fluid balance of an elderly . 1. Assess the client's blood pressure. 2. Check the client's tissue turgor. 3. Determine if the client is thirsty. 4. Maintain an accurate intake and output.
1) may be elevated because of age-related hypertension 2) not accurate because of changes in skin elasticity due to the aging process 3) not reliable indicator; may have diminished sensation of thirst 4) CORRECT—best indicator of fluid status
For an elderly client diagnosed with type 1 diabetes, the nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which of the following? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.
1. The renal threshold for glucose is elevated in the elderly.(1) correct—the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels (2) more expensive procedure (3) provides false-negative readings; may be negative from 0 to 180 mg/dL (4) results are expressed as a percentage according to color change
Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? 1.Tremors. 2. Elevated temperature. 3. Depression. 4. Nocturnal leg cramps. 5. Night sweats. 6. Decreased concentration.
1. Tremors. 2. Elevated temperature 3. Nocturnal leg cramps. .Think about symptoms of withdrawal from alcohol. 1) CORRECT - symptom of withdrawal 2) CORRECT - symptom of withdrawal 3) seen in a depressed client 4) CORRECT - symptom of withdrawal 5) seen in clients with tuberculosis, leukemia, or other infections 6) seen in a depressed client
The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.
2) CORRECT — acts to regulate cardiac rhythm
The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. 2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.
2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. 1. usually small for gestational age 2. correct 3. may have feeding difficulties and poor sucking ability 4. head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottis
The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?
2. Hypotension and respiratory depression. (2) correct—narcotic analgesic used for moderate to severe pain, monitor vital signs frequently
Which observation suggests to the nurse the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid, weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia.
2. Restlessness and rapid, weak pulse. (shock) -{Muscular weakness and fatigue, Dark pigmentation of the skin, Gastrointestinal disturbances and anorexia are signs and symptoms of Addison's disease, but do not indicate a crisis.}
The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of this test is performed? 1. The stem of a vibrating tuning fork is held against the auditory canal until the client indicates sound can no longer be heard. 2. The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. 3. The stem of a vibrating tuning fork is held in the middle of the forehead, and the client's hearing is assessed in both ears. 4. The stem of a vibrating tuning fork is positioned 2 inches behind the client's head, and the length of time sound is heard is documented.
2. The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. 1) inaccurate 2) CORRECT — client should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction 3) the Weber test 4) inaccurate
naproxen sodium (Naprosyn) for the elderly client. 1. Stomatitis and photosensitivity. 2. Bradycardia and dry mouth. 3. Fluid retention and dizziness. 4. Gynecomastia and impotence.
3) CORRECT — NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; adverse effects include headache, dizziness, gastrointestinal distress, pruritus, and rash.
The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The health care provider is able to directly observe the kidney pelvis. 2. An IVP assesses the glomerular filtration rate. 3. The health care provider is able to examine the urinary tract by x-ray. 4. Medication is injected into the urinary system.
3) CORRECT — x-rays of entire urinary tract taken, evaluates kidney function
The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions. 2. Early sexual maturation. 3. Delicate features. 4. Coarse, dry skin.
3. Delicate features. 1. small size but normal body proportions 2. delayed sexual maturity 3. appear younger than chronological age 4. usually see fine, smooth skin
The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use? 1. Benzodiazepines. 2. Marijuana. 3. Barbiturates. 4. Narcotics.
4) CORRECT — narcotics are most often used intravenously
The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement? 1. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye. 2. The client's decreased vision is caused by gradual separation of the retina from the base of the eye. 3. The client's decreased vision is caused by an increase in the size of the vessels in the back of the eye. 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina.
4. The client's decreased vision is caused by gradual destruction and degeneration of the retina. 1) complication of postoperative eye surgery or traumatic injury (hyphema) 2) describes a retinal detachment 3) destruction of the vessels, as well as edema, occurs 4) CORRECT — gradual destruction occurs because of deterioration of the retinal vessels
Sublimation
Diversion of unacceptable drives into socially acceptable channels.
The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV? 1. Provide a route for pain medications. 2. Maintain fluid balance .3. Prevent gastrointestinal upset. 4. Obtain blood specimens for analysis.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? 1) route used for pain medication to ensure absorption, but not primary purpose of IV 2) CORRECT — loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement 3) threat of gastrointestinal upset not primary importance; IV's primary purpose to maintain fluid and electrolyte balance 4) peripheral IV not used for this purpose
The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate? 1. The bowel preparation is incomplete. 2. The patient ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The patient passed the last stool left in the colon.
Strategy: Think about each answer. (1) correct—colon should not have remaining soft stool (2) anything eaten after midnight would not appear as stool by the next morning (3) not expected; need to clean gastrointestinal tract for surgery (4) assumption; not substantiated
An elderly client recently immobilized is ordered to begin passive range-of-motion (ROM) exercises. What should the nurse understand about ROM before initiating this order? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. A sufficient ROM assists the elderly to carry out activities of daily living (ADLs).
Strategy: Think about each answer. (1) inaccurate statement (2) ROM may be limited; full ROM may not be needed or accomplished without discomfort for an elderly client (3) should not be done to point of discomfort (4) correct— emphasis should be on ROMs that support ADLs
Hypoparathyroidism
indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm
Natural passive immunity
occurs when antibodies are passed from mother to fetus via placenta, colostrum, and breast milk
Artificial active immunity
small amounts of specific antigens are used for vaccination; body responds by actively making antibodies
SIDS
support group for parents who have had an infant die from sudden infant death syndrome
During the mother's fourth stage of labor, the nurse palpates the client's fundus in which location?
uterus is normally contracted and palpable at the umbilicus
The nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?
→Right upper abdominal pain. -N/V/ Flatulencia, dyspepsia indicates other GI problems
